Coverage criteria

HealthPartners has medical policies that contain criteria describing how we make coverage decisions for health care services and items. Which coverage criteria apply to your plan depends on which state you or your employer bought your plan in (which might not necessarily be the state you live in). For example, if you live in Wisconsin but your employer is based in Minnesota and bought their insurance there, then Minnesota’s coverage applies to the plan. Which coverage criteria will apply is different if you have a Medicare, MinnesotaCare or Medical Assistance (Medicaid) plan.

We update our coverage criteria regularly and they’re subject to change without notice. For more information, see our coverage criteria terms and conditions.

Sign in to your online account to look at your plan’s information. Contact Member Services if you have any questions. Otherwise, you can use the tool here to search by keyword and filter by product. Criteria won’t apply to Medicare unless Medicare is listed in the product column. This also applies to Minnesota Health Care Programs (PMAP, MinnesotaCare, SNBC, MSC+ and MSHO).

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Third-party coverage criteria

HealthPartners may use clinical coverage criteria developed by third parties including Cohere Health, InterQual^® and MCG Health to guide utilization management.

Cohere Health manages prior authorization requests for a specific list of services (PDF) and plan types. See specific Cohere Health guidelines for all specialties here.

Coverage criteria for Medicare plans

The following coverage rules determine which coverage policies apply to Medicare Cost and Medicare Advantage plans:

• National coverage determinations (NCDs) and/or local coverage determinations (LCDs) from the Centers for Medicare and Medicaid Services (CMS)
• Other published guidance from CMS, including the Medicare Benefit Policy Manual and MLN Matters publications
• Cohere Health guidelines when CMS guidance is absent or not fully established.

Coverage criteria on this site are not applicable to Medicare unless specifically designated. Only services and items listed in the Medicare prior authorization (PA) lists (PDF) require authorization.

Search our coverage criteria

You can search by keyword and apply filters to narrow down your results.

Search tip: If you’re not sure of a keyword’s spelling, type the first three letters of the word followed by an asterisk: *. For example, typing acu* will narrow down the results to acupuncture and other results with that letter combination.